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You must cite the Canadian Journal of Cardiology and the Canadian
Cardiovascular Society as references.
You may not use any Canadian Cardiovascular Society logos or
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If repeating recommendations from the published guideline, do not
modify the recommendation wording.
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181
2012 UPDATE
Heart Failure Management: Focus on Acute and
Chronic Heart Failure
Learning Objectives
At the conclusion of this workshop, participants will be
able to:
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181 ESC 2008
2017-11-19 Copyright 2013, Canadian Cardiovascular Society 6
2012 CCS Heart Failure Management Guidelines Update
Harrisons Principles of Internal Medicine 1st Edition (1950) Ramirez A et al. N Engl J Med 1974;290(9):499-501
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181
CASE 1
CASE 1
No right answer
CASE 1
CCS 2012
We recommend the use of a validated diagnostic
scoring system for patients in whom the
diagnosis of AHF is being considered (Strong
Recommendation, Moderate Quality
Evidence).
e.g. PRIDE score, Boston criteria
CCS 2012
CASE 2
1 2
Dry and Warm Wet and Warm
Increasing
Perfusion/
Cardiac Output 3 4
Dry and Cold Wet and Cold
Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181
1 2
Dry and Warm Wet and Warm
Increasing
Perfusion/
Cardiac Output 3 4
Dry and Cold Wet and Cold
Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181
Admit or discharge?
Treatment options?
CASE 2
e.g. 48 hours
Home dose = 40 mg BID 1) Change to oral diuretics
Bolus = 80 (low) 200 (high) 2) continue current strategy
3) 50% increase in dose
72 hours
Co-primary endpoints
60 days
Clinical endpoints Felker, NEJM 2011
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181
Efficacy:
Patient Global Assessment by visual analog
scale over 72 hours using area under the curve
Safety:
Change in creatinine from baseline to 72 hours
DOSE: patient
global
assessment
DOSE-AHF Conclusions
*Creatinine clearance is calculated from the Cockroft-Gault or Modified Diet in Renal Disease formula. See text for details.
Intravenous continuous furosemide at doses of 5 to 20mg/h is also an option.
RCT: B-CONVINCED
Keep vs. Stop strategy in known HF pts on beta-blockers
Keep was non-inferior to Stop.
Does not delay clinical improvement
Predicts staying on BB in the longer term
Conflict Disclosures
Tang et al, N Engl J Med 2010 Zannad et al, N Engl J Med, 2010
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181
Practical tips
Death
Hospitalization
Failure to improve 1 NYHA functional class
Failure to improve peak VO2 or 6 min walk distance
Absence of reverse remodelling (LVESV or EF)
Absence of improvement in dyssynchrony
Krahn et al, Ont ICD Database Circulation 2011 Poole et al, REPLACE Registry Circulation 2010
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181
Asymptomatic patients
Recommendation
Routine CRT implantation is not currently
recommended for patients with heart failure and
narrow QRS (<120 ms)
Practical tips
Patients enrolled in CRT studies who show benefit
have a QRS duration >150ms, on average. The
benefit in patients with QRS 120ms to 150ms is
less clear
Echocardiography derived parameters of
dyssynchrony cannot be recommended on a
routine basis since clinical utility has not been
established
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181
Practical tip
Jonathan Howlett MD
Disclosures at www.hfcc.ca
Case 1.
34 year old female with NYHA FC II HF with LVEF 29%
BP 130/70, HR 63, Na 139, Creat 100, K+ 4.0
On BB, ACE, diuretic target doses.
A. ARB
B. Aldo Inhibitor
C. Neither
D. Does not matter, going for device anyway
Case 2.
64 year old female with NYHA FC I HF with LVEF 29%
BP 160/70, HR 63, Na 139, Creat 100, K+ 4.2
On BB, ACE, CCB, diuretic target doses.
A. ARB
B. Aldo Inhibitor
C. Neither
D. Both
Case 3.
84 year old female with NYHA FC IIIb HF with LVEF 29%
BP 100/70, HR 70, Na 139, Creat 160, K+ 4.7
On BB, ACE, Digoxin, diuretic optimal doses.
A. ARB
B. Aldo Inhibitor
C. Neither- I will use nitrates preferentially
D. Both
CHARM Proportion of patients with Val-HeFT Probability of freedom from combined endpoint
CV death or hospital admission for CHF (All-cause mortality, cardiac arrest with resuscitation, hospitalization for
worsening HF, or therapy with intravenous inotropes or vasodilators)
CHARM-Added
Permanent study drug discontinuations
Percent of patients Placebo
25 24.2 Candesartan
15
10
7.8
5 4.5 4.1
3.1 3.4
0.7
0
AE/ Hypo- Increased Increased
lab. abnorm. tension creatinine potassium
2006 Recommendation
0 0
0 1 2 3 0 1 2 3
Years from Randomization Years from Randomization
No. at Risk No. at Risk
Placebo 1373 848 512 199 Placebo 1373 848 512 199
Eplerenone 1364 925 562 232 Eplerenone 1364 925 562 232
213 (15.5)
171 (12.5)
Eplerenone Placebo
* p = 0.09
Recommendation 2011
ACE inhibitor
25 60 0.01
(% at target)
Diuretic (%) 49 66 0.01
Suggested addition.
Most of the time, the Aldosterone Antagonist is the way to
go
Osteoarthritis?
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181
Sinus
tachycardia then
multiple PVCs
then VT
PATIENT EVALUATION
PRIOR TO AN EXERCISE PROGRAM
The following should be obtained prior to a tailored exercise
training program:
Establish if the patient has an ICD and if yes, verify if previous shocks
have been delivered and note the programmed VT zone
A written protocol was made to ensure that this would not happen
again. The patient was satisfied with the procedure.
She began training again about 1 year later and still sees her
cardiologist in that same hospital.